From motivation to governance: structural determinants of community health worker engagement in TB and HIV care in Madagascar

Abstract Community health workers (CHWs) are essential to tuberculosis (TB) and HIV responses, yet many programmes rely on volunteer-based models that assume sustained motivation despite weak system support. CHW motivation is widely understood to be shaped by organizational and health-system conditions. We examine how structural and organizational conditions shape CHW motivation in TB and HIV care in Madagascar, drawing on Self-Determination Theory (SDT), which conceptualizes motivation as shaped by the fulfillment of needs for autonomy, relatedness, and competence. We conducted a convergent mixed-methods study (March - October 2024), combining a survey of 408 CHWs across four regions with qualitative data from five focus group discussions with CHWs (n=26) and 24 interviews with institutional actors. SDT was applied within a socio-ecological framework to analyze how individual, community, and health system factors influence autonomy, relatedness, and competence. CHWs reported strong commitment to community health, yet operated under significant structural constraints: Most CHWs lived in economic poverty, with 74.3% reporting household incomes below 100,000 MGA/month (≈ $22.1), while 95.8% CHWs held additional full-time occupations. Motivation was characterized by value-driven commitment alongside dependence on external incentives. However, economic precarity, fragmented remuneration systems, insufficient training and supervision, lack of occupational protection, and weak institutional integration constrained CHWs’ autonomy, relatedness, and competence. Incentive-based approaches enabled short-term participation but generated distortions in task prioritization and undermined trust when payments were inconsistent. CHW motivation emerged as a dynamic outcome of the interaction between strong value-based commitment and programme and health-system conditions. SDT helps explain how fragmented and unreliable support constrains core psychological needs, producing fragile engagement despite high commitment. Strengthening CHW programmes requires the coherent and reliable delivery of predictable remuneration, training and supervision, occupational protection, and formal integration into the health workforce.